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a 1-�) ne / .AV-ek) 11-- <br /> NATURE OF FILING (check all that applies) <br /> Vf'C',,lf un i> - -st ' o •1- [SLAo `, e o` , oh': : <br /> '.1 o,.ln_as -• • •v=r��R 'n e us 0 Trip permit v o 6cige <br /> <_y,tolner: <br /> APPLICANT INFORMATION <br /> El Dealer/seller ❑Lender ❑Escrow/title agent ❑ Owner/buyer ❑ Legal representative <br /> Name:J & M Homes <br /> Address(including city,state,and ZIP):12901 SE 97th Ave.#100 Clackamas, OR 97015 <br /> Phone:503-908-1866 • <br /> Email:tmelchior@jandmhomes.com <br /> HOME INFORMATION (*required) <br /> Home ID number(if known): DMV X-plate number(if known): <br /> WEA (06aSIS <br /> ['Moving in from another state <br /> Has no home ID or X-plate because: ❑Coming out of county deed records <br /> 0 Other:Brand new home <br /> Manufacturer:CMH Model:72DRM28443AH21 Year:2021 <br /> Manufacturer serial number HUD number <br /> ALB0408500RA <br /> ALB040850ORB <br /> *Number of sections:2 *Square footage:1188 *Number of bedrooms:3 *Number of bathrooms:2 <br /> *Type of roofing:Architectural *Type of siding:Vertical wood *Heating:Electric *Cool ing:None <br /> *Date of sale:5/22/2021 *Sales price:90515 *Includes land: ❑Yes 0 No <br /> DEALER INFORMATION (if no dealer, leave blank) <br /> Dealer name: Dealer license number: Dealer address and phone: <br /> J &M Homes, LLC MSD155 12901 SE 97th Ave. #100 <br /> Clackamas, OR 97015 <br /> 503-908-8166 <br /> ❑This manufactured structure is free and clear of all mortgages,deeds of trust,security interests,and liens.I have the <br /> legal right to sell this manufactured structure. <br /> I hereby declare that the above statement is true to the best of my knowledge and belief,and that I understand it is <br /> made for use as evidence in court and is subject to penalty for perjury. <br /> Dealer name(print): De ler signature: Dates/ <br /> J &M Homes, LLC L(/yvl,91-2 7/.2.i/a f <br /> TRANSPORTER INFORMATION (if not moving, leave blank) <br /> Transporter name: Transporter address and phone: <br /> J & M Homes, LLC 12901 SE 97th Ave.#100 <br /> Clackamas, OR 97015 <br /> 503-908-8166 <br /> 440-2952(7/19/COM) Page 2 <br />